Patient information: Lymphedema after breast cancer surgery

LYMPHEDEMA OVERVIEW

Lymphedema is swelling caused by a build up of fluid, usually in the arm in women who have been treated for breast cancer. Lymphedema is one of the most troubling complications that can develop after breast cancer surgery. Many women find that lymphedema worsens the physical and emotional strain of dealing with breast cancer.

The risk of developing lymphedema depends upon the type of surgery you had, the time since surgery, and if radiation therapy was used. Generally, women who undergo more extensive surgery, have many lymph nodes removed, or have radiation therapy to the axilla (arm pit) after surgery are more likely to develop lymphedema. Most women who develop lymphedema do so within four years after their surgery.

More detailed information about lymphedema is available by subscription. (See "Lymphedema: Etiology, clinical manifestations, and diagnosis" and "Lymphedema: Prevention and treatment".)

WHAT IS LYMPHEDEMA?

Lymph is a clear fluid that contains mostly protein and white blood cells (the blood cells that fight infection). Lymph vessels drain lymph from the body's tissues and organs. The fluid is filtered through lymph nodes (also called glands) and eventually drains into the bloodstream (figure 1).

Lymphedema can develop if surgery or radiation treatment affects the lymph vessels.

Women who have multiple lymph nodes removed (a full axillary node dissection) are more likely to develop lymphedema than those who have only sentinel lymph node biopsy. Women who have both surgery and radiation treatment are at even higher risk.

Lymph node biopsy and dissection are discussed in detail in a separate topic review. (See "Patient information: Surgery for breast cancer: Mastectomy and breast conserving therapy".)

LYMPHEDEMA SYMPTOMS

The initial symptoms of lymphedema may include

• A heavy sensation or an aching discomfort in the arm
• Swelling of the affected arm or upper chest
• Difficulty moving the arm
• Stiffness, weakness, or numbness

In some cases, these symptoms develop before swelling is noticeable. Let your doctor or nurse know as soon as possible if you develop any of these symptoms; recognizing and treating lymphedema in the early stages may prevent or slow its worsening over time.

PREVENTING WORSENING OF LYMPHEDEMA

Women with lymphedema can do several things to prevent it from getting worse over time. Expert groups recommend the following:

• Avoid trauma and injury to the affected arm. Injections and acupuncture should not be done in the affected arm, if at all possible. Blood drawing and IV lines are allowed, but be careful to avoid infections.
• Avoid tight fitting clothing, prolonged blood pressure monitoring, or any activity that could interfere with lymph flow in the affected arm.
• Try to prevent infection. Practice careful skin and nail hygiene. Use skin moisturizers to prevent dry, cracked skin. Use an antibiotic cream or ointment on small skin cuts, such as paper cuts. Use protective gloves for household work and gardening. Use an electric razor rather than a razor blade to remove hair in the armpit.
• Avoid heavy exercise and lifting heavy objects with the affected arm immediately after surgery. These activities may increase blood flow, which can worsen edema. Gentle stretching and range of motion exercises, provided by the surgeon, may be used immediately after surgery. Check with your doctor before resuming an exercise program after breast cancer treatment.
• Avoid extreme temperature changes during bathing or washing dishes. Hot tubs, steam baths, and spending time in hot climates may worsen lymphedema.
• Some women notice worsening of their lymphedema during air flight. In the past, many health care providers suggested that women who use compression sleeves wear them during the flight, but this is now controversial. At least one study suggests that short-duration flights (less than 5 hours) do not worsen lymphedema, and that wearing a compression sleeve during a short flight may actually increase arm swelling.
• Keep your weight under control. Obesity can worsen lymphedema and may limit the effectiveness of compression pumps or sleeves.
• Avoid resting your arm below your heart or sleeping on your arm for prolonged periods.
• Contact your doctor or nurse if the affected arm develops a rash, becomes red, blistered, or warm, or if you get a fever (temperature greater than 100.4ºF or 38ºC). These symptoms could signal the beginning or worsening of lymphedema.
• If you develop lymphedema many years after surgery or have worsening lymphedema, contact your doctor or nurse immediately.

LYMPHEDEMA TREATMENT

There is no cure for lymphedema. The main goals of treatment are to control swelling, relieve symptoms, and prevent the swelling from worsening over time. Treatment should begin as soon as possible. A healthcare provider or program with expertise in treating lymphedema can be especially helpful.

Because medicines are of little benefit and can sometimes be harmful, the most common approaches are nonpharmacologic (ie, they do not involve medicines).

Arm elevation — Although elevation of the arm is not an effective treatment by itself, it may be recommended in conjunction with other therapies [1].

Exercise — After the immediate recovery phase, moderate exercise is recommended. If the arm begins to hurt, lie down and elevate the arm. Walking, swimming, light aerobics, bike riding, and yoga are all recommended to improve lymph flow and reduce swelling. Avoid repetitive movements against resistance with the affected arm, such as scrubbing or pushing/pulling heavy objects.

Some clinicians recommend avoiding certain forms of exercise, including rowing, tennis, golf, skiing, squash, racquetball, or other vigorous repetitive movements. However, there is no evidence that these activities promote or worsen lymphedema.

Compression garments — Applying pressure to the arm can encourage fluid movement and ultimately reduce swelling. Pressure can be applied by using an elastic lymphedema sleeve (picture 1A-B) or by wrapping the arm in elastic bandages. Some people require a custom-made garment if a standard size sleeve does not fit.

A lymphedema sleeve is preferred to bandaging because it provides increased pressure at the wrist, which gradually lessens towards the axilla; this helps to move fluid better than bandages, which have equal pressure at all points along the arm. Whichever method is used, proper fit is important to avoid worsening edema in any one area of the arm.

Some clinicians recommend the garment be used for up to 24 hours per day, while others recommend use only during waking hours or exercise. Compression garments should be replaced every four to six months, or when they begin to lose their elasticity.

Massage therapy — Massage or manual lymphedema therapy (MLT) may help to mobilize lymph fluid. MLT applies light pressure to the arm and torso to mobilize fluid from the fingers and hand to the upper arm and chest.

Manual lymphedema therapy is usually used in conjunction with compression garments and therapeutic exercise. Whenever possible, patients should see practitioners trained in MLT.

Complete decongestive therapy — Complete decongestive therapy uses a combination of massage, skin care, exercise, and compression garments. It is considered an effective treatment for lymphedema that is unresponsive to compression therapy alone. The treatment is performed by a physical therapist until arm swelling is improved (several weeks to months), followed by a maintenance program.

Intermittent pneumatic compression — Intermittent pneumatic compression may be used if you do not respond to massage or pressure garments. This treatment uses a sleeve that is intermittently blown up with an air pump, beginning at the lower end of the arm and progressing towards the shoulder.

Intermittent pneumatic compression is recommended only for patients who have not improved with other therapies (massage, compression garments, exercise). It is not useful as a sole form of therapy, but is usually combined with complex physical therapy.

Drug treatment — Medicines are not usually helpful for treating lymphedema and in some cases, medicines can be harmful.

Surgery — Surgery is rarely performed to treat lymphedema following breast cancer therapy. Some specialized centers have performed lymphatic microsurgery, which involves draining lymph fluid into blood vessels. A newer technique, microsurgical lymph node transplantation, is currently being studied.

IMPACT OF LYMPHEDEMA

While lymphedema is not a life-threatening condition, it can have a major impact on your quality of life. A change in how your arm looks can be distressing.

• After breast cancer surgery, many women are worry about how they look; having a swollen or misshapen arm can make this worse.
• If lymphedema affects the ability to use your arm, this can affect your quality of life, particularly if it is your dominant arm (eg, right arm if you are right-handed).
• Lymphedema can reduce tissue healing and occasionally causes chronic pain. For these reasons, prevention and early treatment of lymphedema are recommended.

CLINICAL TRIALS

Progress in treating breast cancer requires that better treatments be identified through clinical trials, which are conducted all over the world. A clinical trial is a carefully controlled way to study the effectiveness of new treatments or new combinations of known therapies.

One example of a clinical trial that is investigating ways to reduce the incidence of lymphedema after breast cancer therapy is called CALGB 70305. This trial is currently enrolling women to determine if a combination of education, use of light arm weights with exercise, a light compression sleeve with vigorous activity, and regular breathing exercises can reduce the risk or severity of lymphedema after axillary lymph node dissection. Women are encouraged to enroll if possible. More information can be found online at www.cancer.gov/clinicaltrials/CALGB-70305.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: Surgery for breast cancer: Mastectomy and breast conserving therapy

Professional Level Information:
Breast reconstruction in women with breast cancer
Lymphedema: Etiology, clinical manifestations, and diagnosis
Lymphedema: Prevention and treatment
Mastectomy and breast conserving therapy for invasive breast cancer

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• National Cancer Institute

       1-800-4-CANCER
       (www.nci.nih.gov)

• People Living With Cancer: The official patient information

      website of the American Society of Clinical Oncology
      (www.cancer.net/portal/site/patient)

• National Comprehensive Cancer Network

      (www.nccn.com)

• American Cancer Society

       1-800-ACS-2345
      (www.cancer.org)

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/healthtopics.html)

• Susan G. Komen Breast Cancer Foundation

       (www.komen.org)

• National Lymphedema Network

     (www.lymphnet.org)

Patient support — There are a number of online forums where patients can find information and support from other people with similar conditions.

• About.com Breast Cancer Forum

      (http://breastcancer.about.com/forum)

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